What is the next step in treating a term newborn with a heart rate below 60 bpm after positive-pressure ventilation?

Neonatal Resuscitation: Management of Persistent Bradycardia

Before initiating chest compressions in this newborn with a heart rate of 70 bpm on positive-pressure ventilation, you must first check for adequate chest movement to ensure effective ventilation is being delivered. 1, 2

Why Check Chest Movement First?

The critical principle in neonatal resuscitation is that bradycardia in newborns is nearly always caused by inadequate lung inflation or profound hypoxemia, not primary cardiac dysfunction. 3, 1, 2 Therefore, establishing effective ventilation is the single most important step before escalating to chest compressions.

The Ventilation-First Approach

• Ventilation is the most effective action during neonatal resuscitation, as it addresses the root cause of neonatal bradycardia. 1
• The heart rate of 70 bpm indicates inadequate ventilation rather than a need for immediate chest compressions. 1
• Improvement in heart rate is the primary indicator of effective ventilation, so if the heart rate remains low, the ventilation technique must be assessed and corrected first. 1

The Correct Sequence

Step 1: Verify Effective Ventilation

• Check for visible chest rise with each breath to confirm adequate ventilation is being delivered. 1
• If chest movement is absent or inadequate, troubleshoot the ventilation technique:
  • Reposition the airway
  • Check mask seal
  • Consider increasing inflation pressure (may need ≥30-40 cm H₂O in some newborns without spontaneous ventilation) 1, 2
  • Ensure ventilation rate of 40-60 breaths per minute 1, 2

Step 2: Only Then Consider Chest Compressions

• Chest compressions are indicated only if the heart rate remains <60 bpm despite 30 seconds of adequate ventilation with supplemental oxygen. 1, 4, 2
• The current heart rate of 70 bpm does not yet meet the threshold for chest compressions. 3
• According to AHA guidelines, if the pulse is <60 per minute with signs of poor perfusion despite support of oxygenation and ventilation, begin chest compressions. 3

Why Not the Other Options?

Not Chest Compressions (Yet)

• The heart rate of 70 bpm is above the <60 bpm threshold that mandates chest compressions. 3
• Starting compressions prematurely without ensuring effective ventilation wastes critical time and doesn't address the underlying problem. 1, 2

Not Endotracheal Intubation (Yet)

• Intubation should be considered if adequate ventilation cannot be achieved with bag-mask ventilation, but this determination requires first checking chest movement. 2
• The sequence is: assess ventilation effectiveness → optimize bag-mask technique → consider intubation if still inadequate. 2

Not Umbilical Venous Catheter (Yet)

• Vascular access is needed for medications (epinephrine) or volume expansion, but only after chest compressions have been initiated for persistent bradycardia <60 bpm despite adequate ventilation and compressions. 3
• This is premature at a heart rate of 70 bpm without confirmed adequate ventilation. 3

Critical Pitfall to Avoid

The most common error in neonatal resuscitation is proceeding to advanced interventions without first ensuring effective ventilation. 1, 2 The vast majority of newborns will respond to proper ventilation alone, making it essential to verify chest movement before escalating care. 3, 1